The aim of this thesis was to increase the knowledge about how managers in Swedish healthcare organisations handle their manager role in relation to the medical profession.
The findings show that managers have a weak, partly absent, and rather ambiguous manager role in relation to the medical profession.
Few managers used a management-based discourse to construct the manager role in their organisations. Instead, a profession-based discourse was predominant, where managers frequently used the attributes “physician” or “non-physician” to categorise themselves and other managers in their manager roles. Some managers also combined the two discourses in a “yes, but...” approach to management in the organisation. (IV).
When strategies for managing physicians were addressed, many described physician-specific strategies that helped managers to manage physicians in daily work, but seemed to weaken the manager role in the organisation (III). Regarding physicians’
sickness certification, which is the clinical practice that has been the context for this study, many physicians experienced a lack of management concerning these tasks (I, II).
8.1 IMPLICATIONS FOR PRACTICE
This thesis has explored and analyzed one aspect of daily life in healthcare
organisations: how managers handle their role in relation to the medical profession – whether it is their own medical profession or that of others.
How the manager role is handled and regarded within healthcare organisations constitutes part of the organisational conditions for the role taking of all employees in the organisation - managers, physicians, as well as other healthcare professionals. The findings in this thesis indicate that there is a need to support healthcare managers in their role taking in the organisation - both those managers who also are physicians and managers with other underlying professions. A weak and ambiguous manager role may have negative consequences not only for the work of managers, but also for that of physicians and other healthcare professionals, and for the quality of care.
There seems also to be a need to strengthen management regarding sickness certification tasks. The findings in this thesis show that many physicians lack management regarding this task, despite the fact that they experience a number of problems in their sickness certification practice. This may have negative consequences both for physicians and patients.
8.2 IMPLICATIONS FOR RESEARCH
Despite the strengthening of the formal manager position through government initiatives during the last three decades, previous research show that the medical profession has managed to retain its overall dominance in the healthcare organisation.
The findings in this thesis indicate that healthcare managers themselves may contribute to this situation. Rather than potentially contributing to an emerging professionalization
process in the role of manager, managers seem to contribute to preserving the
dominance of the medical profession and in different ways eroding the legitimacy and authority of the manager position. This hypothesis needs to be further studied.
This thesis found that managers with different underlying professions and on different managerial levels contribute to construct a weak, partly absent and ambiguous manager role in relation to the medical profession. To explore whether there are differences between or within groups was not within the scope of this thesis and still needs to be studied.
The “yes, but...” approach to management which was identified in the thesis raises questions about the organisational conditions for managers’ role taking in healthcare and about a potential prevalence of “strategic ambiguity” in healthcare organisations.
To further explore the organisational conditions for managers’ role taking in healthcare organisations would be of great interest for future research.
Another issue for future research concerns management of sickness certification tasks.
The results in study II showed that despite the many interventions to increase management of how sickness certification of patients is handled in healthcare many physicians did not experience such management. This finding raises questions about possible reasons for this. Further studies using different theories and perspectives are needed in order to explore this.
ACKNOWLEDGEMENTS
I want to express my deepest gratitude to all who have contributed to making this work possible. First and foremost, I want to thank all managers and physicians, who
contributed with their time and experiences in the FGDs, the individual interviews, and the questionnaires
I especially want to thank my supervisors:
Kristina Alexanderson, my main supervisor, who so generously introduced me to the world of science at KI. Thank you for excellent scientific guidance and clarity, and for always trusting in me.
Angelique de Rijk, for being there and stretching my intellectual capacity to its utmost limits.
Lena Wilhelmsson, for your tremendous support and inspiring never-ending scientific conversations.
Mats Brommels, for excellent and precise advice at times when advice was needed.
I am also deeply grateful to:
My colleagues and friends at the Division of Insurance Medicine at KI for all your support. A special thank you to my dear friend Marjan Vaes for helping with the figure in Study III.
My colleagues at the Medical Management Centre at KI for constructive criticism during this process. A special thank you to Christer Sandahl for helping with my first grant applications and for fruitful collaborations during the years.
Miriam Eliasson, my co-author on study IV for inspiring analytical discussions over data.
Linda Sundblad, my co-author on study I for inspiring collaboration in doing the FGDs and analyzing the data.
Anna Löfgren Wilteus, co-author in study I, for sharing experiences as PhD students and for all your help with absolutely everything.
Christina Lindholm, first author of Study II, for support and for making discussions on statistics interesting.
All participants in the Organizational Pedagogic Seminar at the Department of
Education, Stockholm University, who gave me constructive criticism and boosted my self confidence when I needed it the most. A special thank you to Marianne Döös for encouraging emails.
Jan Forslin, who long ago accompanied me when I took my first step into the scientific field of management and leadership.
Ingalill Holmberg, for the valuable comments at my halftime seminar that encouraged me to continue my work with what I thought was important.
Marie Söderstedt, Giorgio Grossi, Heli Ristiniemi and my group members and friends at the Stockholm Stress Center, for helping me recover my sleep.
My dear friend Erica Falkenström, for always being there and sharing whatever needed to be shared. And to my friend Marita, for waiting...
S. Veronica O.P. and the community at Berget, for letting me share your daily rhythm and putting myself and my work in context during ten important days in the final parts of my thesis work.
The Grubb Institute of Behavioural Studies in London for letting me participate at an early stage of this work in their workshops introducing me to the works of Bruce Reed.
Jane Wigertz and Patricia Ödman, who skilfully and patiently revised the language in my English manuscripts.
And last but not least I want to thank:
My mother Lena and my father Hans, for being there with love, shelter and something to eat when I was so deeply involved with my work that I forgot. And for supporting me in my work, even though we all so painfully know that there are much more important things in life than a thesis.
My beloved husband Per-Inge, for always being there and sharing the experiences of life - for better and for worse. Without your unconditional love and support this work would not have been possible.
Hilma, for putting up with not seeing much of your mother lately - and still - standing there full of joy and energy. You are the best gift in my life and make me so
tremendously proud!
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Financial support for this thesis was provided by the Swedish Council for Working Life and Social Research (FAS) (#2007-1143 and #2009-1758), AFA Insurance and
Karolinska Institutet. Data collection was financially supported by the Swedish Ministry of Social Affairs, Stockholm County Council, Ötergötland County Council, and the former Stockholm Social Insurance Office and the Östergötland Social Insurance Office.